Treatment of Adolescent Alcohol Abuse and Dependence.

Most adolescents under the legal drinking age consume alcohol. For many of them, their drinking patterns evolve into alcohol abuse and dependence. Treatment of these adolescents must take into consideration their physical, psychological, and social development. Therefore, different treatment approaches may be needed for adolescents than for adults.

1 The terms "alcohol abuse" and "alcohol depend ence" are based on the diagnostic criteria in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. cents become alcoholabusing adults (Tem ple and Fillmore 1986).
This article reviews the prevalence of alcohol abuse and dependence among ado lescents and examines the characteristics of abuse and the unique needs of adolescents that must be considered when devising treatment plans for these patients. The article also discusses the contents and effectiveness of current treatment ap proaches and addresses future directions for adolescent alcoholism treatment research.

PREVALENCE OF ADOLESCENT ALCOHOL USE AND ABUSE
Alcohol use is widespread among adoles cents. In an annual survey of high school students, almost 90 percent of the seniors reported having at least tried alcohol (Johnston et al. 1993 found that almost onethird of high school seniors had five or more drinks on at least one occasion in the previous 2 weeks. How many adolescents have serious alcoholrelated problems? Prevalence rates of alcohol abuse and dependence as determined in community studies vary widely. Kashani and colleagues (1987) found that 5.3 percent of the 15yearolds studied fulfilled the criteria for alcohol abuse or dependence listed in the Diag nostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III). Another study reported a lifetime diagnosis of alcohol abuse or dependence as defined in the 1987 Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) in 32.4 percent of adolescents ages 17 to 19 (Reinherz et al. 1993). In addition, a survey of students in grades 7 through 12 identified 28 percent of male and 16 percent of female adolescents as problem drinkers (Donovan and Jessor 1978).
These studies, however, must be inter preted with caution. The diagnoses in these surveys were based on an arbitrary definition of problem use or on the DSM criteria, which have been established for adults. The validity of these definitions for a diagnosis in adolescents remains controversial (Bukstein and Kaminer 1994). For example, the DSM-IIIbased diagnosis of alcohol dependence relies heavily on the presence of specific with drawal symptoms, which rarely are found in adolescents. Moreover, establishing a diagnosis of alcohol abuse on the grounds of medical or social problems or function al impairment may be doubtful, because these symptoms also could be caused by other problem behaviors, psychiatric disorders, or adverse environmental cir cumstances that often are found in alcoholabusing adolescents.

CHARACTERISTICS OF ADOLESCENT ALCOHOL ABUSE
Alcoholabusing adolescents may require not only a specific, ageappropriate set of diagnostic criteria but also treatment ap proaches different from those for adults. Adolescent drinking behavior has special characteristics that set it apart from adult drinking behavior and that should be rec ognized if treatment is to be effective.
One characteristic of adolescent alco hol use is the variability of drinking pat terns. For most people, these patterns change between adolescence and young adulthood and then stabilize (NIAAA 1990). Temple and Fillmore (1986), for example, found that only onehalf of the heavier drinkers at age 18 continued the same drinking pattern 12 years later. Therefore, alcohol abuse in many adoles cents may reflect a developmental phase that ceases over time and requires little or no intervention. To date, no objective criteria exist to determine which adoles cents need or can benefit from treatment.
Compared with adults, adolescents are more likely to use and abuse other drugs in addition to alcohol, potentially compli cating treatment (Bukstein and Van Hasselt 1993). The reasons for multiple drug use among adolescents are not com pletely clear, but temperament or person ality traits, such as disinhibition or sensationseeking behavior, may encour age multiple drug use.
However, adolescents are less likely than adults to suffer from alcoholrelated chronic medical problems and psycholog ical withdrawal symptoms (Bukstein and Van Hasselt 1993). This may be a result of their relatively short drinking career, and it is possible that overt health prob lems will develop after significant alcohol consumption over a longer period of time. Adolescence frequently marks the onset not only of alcohol use and abuse but also of psychiatric disorders, such as conduct disorder (i.e., a pattern of antisocial behav iors, for example, lying, stealing, fighting, and truancy), major depression or bipolar disorder (i.e., alternating episodes of depression and mania), and anxiety disor ders (Bukstein et al. 1989). These coexist ing psychiatric disorders may increase adolescents' vulnerability to alcohol abuse or may be the consequence of alcohol abuse (Bukstein et al. 1989). Attention to psychi atric disorders, therefore, is crucial in the treatment of alcoholabusing adolescents.

THE UNIQUE NEEDS OF ADOLESCENTS IN TREATMENT
In the past, adolescents generally received treatment originally designed for adults. Only in 1974 did the first facility specifi cally for adolescent substance abusers open as an inpatient program at St. Mary's Hospital in Minneapolis, MN (Wheeler and Malmquist 1987). Based on clinical observation, treatment providers since then have recognized increasingly that adolescents are exposed to specific influences and have special needs (see textbox) during the transition from child hood to adulthood. Consequently, they require treatment approaches that under stand and address their position and roles in family and society, their cognitive and social development, the environmental influences on their behavior, and their educational requirements.
The position as a dependent family member is a salient aspect of an adoles cent's life and can have important implica tions for the development and treatment of alcohol abuse. The family should provide support, consistent behavioral limits, and models of appropriate behavior (including drinking behavior). Deficits in these do mains, including parental alcohol or other drug abuse, are seen as risk factors for adolescent alcohol abuse or dependence (Kumpfer 1989). These deficits also can influence treatment outcome by hampering the family's ability to encourage the ado lescent's entry into treatment, to participate in treatment, and to provide adequate structure and guidance afterward.
Adolescents undergo not only physical maturation but also cognitive maturation (e.g., development of abstract thinking) and social maturation (e.g., development of values to guide behavior). In addition, they must develop a separate identity and in dependence from their parents and build appropriate societal and individual relation ships to prepare for adult life with a job, marriage, and family. In this transition period, adolescents experiment with a wide variety of attitudes and behaviors. Success ful treatment programs should provide guidance and support through these impor tant stages in adolescent development.
Environmental influences also con tribute significantly to the developing patterns of alcohol use in adolescents. Peer behavior (including alcohol use) and attitudes, media messages, community values, and social support systems all help shape adolescents' beliefs about alcohol and their drinking patterns (Kumpfer 1989). Therefore, it is important that treat ment interventions foster the development of effective social skills to enhance resis tance to negative peer influences.
Finally, adolescents' ongoing educa tion or vocational training also must be considered when treatment programs are developed. To prepare for adult life, adolescents must achieve at least a basic level of academic skills, and treatment programs therefore should require or strongly encourage completion of a sec ondary education.

CURRENT TREATMENT APPROACHES
In a 1991 survey, adolescents under age 18 constituted about 6 percent of the patients in alcoholism and drug abuse treatment units (U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Ad ministration 1993). About 35 percent of these clients were treated for alcoholism and about 40 percent for alcoholism and other drug abuse. The same survey showed that 3,299 treatment units offered specialized programs for youth. These programs offer a variety of inpatient and outpatient treatment modalities (table 1). The predominant inpatient approach remains the Minnesota model, a group oriented 28day program that is based on a 12step program of recovery (Wheeler and Malmquist 1987). Counseling, attendance at group meetings, information about alco holism and related problems, family thera py with individual families and multifamily groups, and the use of workbooks are common components of this and related programs. Aftercare following program completion varies in content and often centers on attendance at community Alcoholics Anonymous (AA) meetings. Although most meetings include partici pants who represent a wide age range, some communities have AA groups that are attended predominantly by youth and deal with issues more relevant to adolescents.
Residential programs, such as thera peutic communities or halfway houses, usually have a similar orientation to that of inpatient programs but offer longterm treatment. Also, they often are designed to serve youth with more severe drug abuse or coexisting psychosocial prob lems (Bukstein and Van Hasselt 1993).
Outpatient treatment modalities, which also are based mainly on 12step pro grams, range from very intensive day programs and partial hospitalization to regular or occasional sessions with an individual therapist. The primary advan tage of outpatient treatment is that it is often less disruptive to the adolescent, who can participate in treatment while remaining in the community. However, this also can be a disadvantage because the adolescent still is exposed to circum stances, stressors, and problems that may have contributed to the alcohol problems. In addition, the treatment provider has less control over the adolescent's behav ior outside treatment hours.

VARIATIONS IN CURRENT TREATMENT APPROACHES
As with alcohol and other drug abuse treatment for adults, treatment approaches for adolescents currently are undergoing rapid changes, for example, by reducing their costs and emphasizing less restric tive treatment modalities. Many tradition al 28 or 35day inpatient programs are decreasing their length of stay and are expanding outpatient and partial hospital ization services. Some programs that are unable to achieve this transition are clos ing or reducing their capacity (Spicer 1993). It still is uncertain if and how these trends will affect treatment.
At the same time, there is a growing interest in alternative approaches (Bukstein and Van Hasselt 1993). Many programs have begun to incorporate a variety of family or behavioral treatments, health services, vocational and educational services, and recreational activities in addition to 12step principles. Other initiatives treat alcoholabusing youth as part of a comprehensive system of ser vices for hardtoreach, multiproblem adolescents and their families (Henggeler 1991). In these programs, case managers and multidisciplinary teams from differ ent social service agencies and treatment programs coordinate services and care. Also, increasing emphasis is placed on providing help to the adolescents in their own community and in as "normal" a setting as possible.
Some treatment programs are paying more attention to subpopulations of adoles cent patients. They specifically address adolescents with coexisting psychiatric disorders, homeless youth, innercity youth, youth from specific racial or ethnic groups, and adolescents in the juvenile justice system (Bukstein and Van Hasselt 1993).
Especially for adolescents with coexist ing psychiatric disorders, psychological and behavioral interventions appear to be used increasingly (Bukstein and Van Hasselt 1993). Many of these approaches originally were developed for prevention programs and have been adapted for treat ment. Examples of such interventions include improvement of social skills (e.g., communication and assertiveness skills), problemsolving skills, anger control training, and family counseling (Bukstein and Van Hasselt 1993). The latter may contain contingency contracting, an explic it agreement between the parent(s) and the adolescent about the rules and expectations of the household. Contracts specify the consequences if the rules are violated and the rewards if they are obeyed.
The increased recognition of coexist ing psychiatric disorders also has prompt ed more aggressive efforts to use pharmacologic treatment with these pa tients. For adolescents as well as adults, the use of antidepressants, lithium, and other agents is becoming more accepted. For adolescent alcohol abusers who have attentiondeficit hyperactivity disorder, however, treatment with stimulants re mains controversial because these medi cations also have a potential for abuse (Bukstein and Van Hasselt 1993).

EVIDENCE OF TREATMENT EFFICACY
Although different treatment approaches are being used for adolescents with alco hol abuse or dependence, rigorous evalua tion of their effectiveness is scarce. Many studies were flawed by various method ological problems, including poor pre assessment measures, lack of clear definitions and measures of treatment success or relapse, and insufficient fol lowup procedures. The available studies generally suggest beneficial effects of treatment for adolescents but do not establish the superiority of any specific approach (Catalano et al. 1990(Catalano et al. -1991. Two studies that evaluated several adoles cent treatment options, the Drug Abuse Reporting Program and a study for the Pennsylvania substance abuse system, found that adolescents in outpatient pro grams for alcohol abuse, but not those in inpatient programs, reported a moderate reduction in alcohol use (Sells and Simpson 1979;Rush 1979). In contrast, in the Treatment Outcome Prospective Study (TOPS), Hubbard and colleagues (1985) noted significant improvements of alcoholrelated problems in both inpa tients and outpatients. This study showed that patients in residential settings report ed a greater reduction in heavy alcohol use than did outpatients.
In a study of adolescent treatment in an Alcoholics AnonymousNarcotics Anonymous (AANA) model inpatient program, both completers and noncom pleters of the program had reduced alco hol and other drug use after treatment (Alford et al. 1991), but completers showed lower relapse rates 6, 12, and 24 months after discharge than did noncom pleters. Among males in both groups, however, relapse rates had exceeded 60 percent by the 1year followup. In con trast, females only reported relapse rates of 30 percent at the 1year followup and 39 percent at the 2year followup. And even among the adolescents of both gen ders who had relapsed, 17 percent report ed improvement in their social behavior at the 2year followup.
All these studies of adolescent alco holism treatment, however, are limited by the absence of control groups or treat ments, the lack of control over the high variability of treatment content among programs, and the absence of data on the treatment effects on areas of psychosocial functioning.
As indicated by the AANA study, many adolescents relapse into alcohol abuse patterns within a relatively short time after treatment completion. In a recent review of adolescent treatment research, Catalano andcolleagues (1990-1991) identified factors influenc ing treatment outcome and relapse risk. For example, earlier and heavier alcohol abuse, multiple drug abuse, deviant be havior, and criminal involvement were associated with noncompletion of treat ment or higher relapse rates. Posttreat ment predictors of relapse included thoughts and cravings for alcohol, little involvement in school or work, and un satisfactory leisuretime activities.

WHAT MAKES TREATMENT EFFECTIVE?
Despite the inconclusive results of the studies mentioned above, some general recommendations can be made for adoles cent treatment modalities (Fleisch 1991). As with all treatment programs, the pri mary goal should be to achieve and main tain abstinence from alcohol and all illicit drugs. Treatment should improve the over all psychosocial functioning (e.g., educa tional, vocational, family, and interpersonal functioning) of the adolescent as well as the specific areas (e.g., problemsolving or anger control skills) that particularly may help the adolescent to avoid relapse.
Several specific treatment characteris tics have been associated with improved abstinence and lower relapse rates (Fleisch 1991;Friedman and Beschner 1985) and can be used as guidelines for the treatment of adolescents with alcohol use problems: • Treatment should be intensive and of sufficient duration to achieve changes in attitude and behavior. What consti tutes "sufficient" may depend on the treatment modality and the needs of the individual patient.
• Treatment should be as comprehensive as possible and target multiple do mains of the adolescents' lives. These include coexisting psychiatric disor ders; vocational or educational needs; recreational activities; birth control services; education about alcohol and other drug abuse; and information about relevant medical issues, such as HIV infection and AIDS.
• Treatment should be sensitive to the cultural and socioeconomic realities of the adolescents, their families, and their environments. This can be achieved by having a staff that repre sents the racial and ethnic variety of the adolescents in treatment and by assisting families to obtain additional social services or financial resources.
• Treatment should encourage family involvement and improvement of communication among family mem bers. The goal should be to enhance the ability of parents to provide proper guidance consistently for their chil dren. To this end, addiction patterns in the parents also must be recognized and treated and their contribution to the adolescents' addiction evaluated.
• Treatment programs should incorpo rate a wide range of social services, such as juvenile justice, child welfare, and recreational programs, to assist the adolescents and their families in developing an alcoholandother drugfree lifestyle. Programs should require or strongly encourage adoles cents' attendance at selfsupport groups, such as AA, to provide a drugfree peer group.
• Aftercare is essential and should rein force the changes that have been achieved during primary treatment.

FUTURE DIRECTIONS FOR ADOLESCENT ALCOHOLISM TREATMENT RESEARCH
The available outcome studies have shown that a significant portion of alcohol abusing adolescents do not respond to treatment with desired outcomes, such as abstinence, reduced drinking, or improve ments in psychosocial functioning. In the TOPS study, between 29 and 40 percent of the patients (depending on the treat ment modality) reported heavy alcohol use in the 12 months after treatment (Hubbard et al. 1985). To improve treat ment outcome in adolescents who do not respond satisfactorily to current treatment approaches, several issues must be ad dressed in future research.
First, ageappropriate diagnostic crite ria must be established to improve the identification of youth with alcohol abuse or dependence. Further research into the development of adolescent alcohol use is needed to recognize adolescents at risk for continued alcohol abuse and in need of treatment.
Second, treatment studies need more rigorous experimental design and method ology. This includes (1) comprehensive, standardized assessments before, during, and after treatment with, for example, assessment tools developed specifically for adolescents, such as the Problem Oriented Screening Instrument for Teen agers (POSIT) (National Institute on Drug Abuse 1990) and the Personal Experience Inventory (Winters et al. 1993); (2) thor ough inventories of treatment content (i.e., what kind of modalities are used and in what intensity); (3) manualguided proce dures for implementing specific interven tions with specific contents; and (4) the use of appropriate controls.
Third, treatment outcomes must be evaluated more thoroughly, with careful followup for several years. Outcome studies not only should consider absti nence or relapse status but also should include all changes in drinking patterns and psychosocial functioning.
Fourth, nontraditional treatments, such as behavioral interventions (e.g., social and problemsolving training, cognitive therapy, and parentmanagement training to assist parents in setting behavioral limits) and medication treatment, should be evaluated further, especially in patients for whom more traditional approaches are not effective. As with adults, it is likely that certain types and intensities of treat ment may be more suitable for certain adolescents. Patienttreatment matching, that is, designing an individualized treat ment plan for each patient, will therefore be a critical part of treatment research.
Finally, treatment studies also should evaluate efficacy in specific populations of adolescents with regard to age, race, gender, ethnicity, socioeconomic status, and comorbid psychiatric status.

SUMMARY
By the time they graduate from high school, 90 percent of adolescents have tried alcoholic beverages, and many of them drink regularly. A significant por tion of adolescents will suffer psychologi cal and social problems because of abusive patterns of alcohol use and will require intervention. To treat them suc cessfully, health care professionals must take into account the adolescents' special developmental status and position in the family and society. Although many ado lescents can be helped by current treat ment programs, further research is needed to establish what kind of treatment, and at what intensity and duration, is necessary to reduce alcohol consumption and pre vent relapse in patients currently unre sponsive to treatment. ■